5.Educate and have patient
demonstrate relaxation techniques to help pain management.

6.Reposition every 2 hours
beginning 8 AM.

Rationale:

1.Initial assessment provides
baseline and comparison.

2.Usually altered in acute pain.

3.Medication will help in providing
comfort.

4.Lack of sleep/rest impedes
healing process.

5.Will help to relieve tension to
reduce stress and pain level.

6.Repositioning aids in prevention
of pressure ulcers and aids in comfort.

Client Response:

1.Patient states 7 on pain scale.

2.Vital signs 97.7 temp.BP 123/83

HR 69RR 18

3.After PCA pump patient states
pain 5 on pain scale.

4.Patient agrees to take pain
medicine as ordered.

5.Patient listened about relaxation
and performed some deep breath exercises & watched TV for distraction.

6.No pressure ulcers & repositioned
with patient assistance.

Summarize impressions of client progress
toward outcomes / problem resolution:Patient is stable and pain level lowered from 7 to 5 on pain scale.Patient was using PCA pump as ordered
and agreed to take PO meds at bedtime in order to assist sleep.Patient ate breakfast and lunch and
was compliant with PT as ordered.No
family support so patient was advised on importance of following all MD orders
upon discharge.